China has been an aging society since 1999 and currently has the largest elderly population in the world, accounting for one-fifth of the total global elderly population. It is expected to reach the largest by 2050, which is projected to be 300-400 million. And 1/3 of older adults are reported to suffer from chronic pain, many of which severely affects their daily lives. Despite this, many of them are not well treated for pain. As a result, the treatment of chronic pain in older adults has become a priority in pain management today. And this year’s October 16 – China Analgesia Day has also set the theme to focus on the pain of the elderly. Ma Songhe, Pain Department, Henan Provincial People’s Hospital Pain treatment for the elderly can be divided into pharmacological and non-pharmacological treatments. The physiological characteristics of the elderly and the frequent complication of multiple system diseases determine their own characteristics of chronic pain treatment.1. Pharmacological treatment Analgesics mainly include acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), weak opioids such as codeine and tramadol and opioid morphine. For chronic mild to moderate musculoskeletal pain in the elderly, the American Geriatric Society recommends acetaminophen as the first choice. This is because acetaminophen acts primarily centrally and has weak peripheral effects, making it safer compared to non-selective NSAIDs. Non-selective NSAIDs are relatively more toxic to the kidney and stomach, with a 4% annual increase in the risk of serious complications at age >65 years. Older adults, especially those with reduced renal perfusion or cardiovascular disease, are more dependent on renal prostaglandin synthesis to maintain renal blood flow. The use of NSAIDs in the presence of cardiovascular disease can increase the incidence of renal failure and congestive heart failure by 10-fold. In contrast, selective COX-2 inhibitors are relatively less toxic to the gastrointestinal tract, but have the same effect on renal function. And long-term use can significantly increase the incidence of myocardial infarction and stroke. Therefore, great care is needed when using NSAIDs in the elderly. Weak opioids are mainly used for moderate pain. The one that is used more often is tramadol. Because of its pharmacological properties, it is more appropriate for use in older adults with gastrointestinal (constipation) and renal problems. Recently, tramadol addiction has been reported from time to time. The maximum dosage is 400 mg/d. If the pain is not effectively relieved beyond this dosage, the dosage should not be increased, and an additional adjuvant or a more potent analgesic with a three-step medication should be used. If the dose of tramadol is increased without restriction, the possibility of addiction is greatly increased. In addition, the use of extended-release dosage forms is now favored because they maintain stable blood levels and reduce the potential for addiction. For severe chronic pain for which acetaminophen and tramadol are ineffective, opioids may be considered. Most people are concerned about addiction when using opioids, but numerous studies have concluded that opioids rarely cause addiction in the treatment of pain and that tolerance does not affect long-term opioid use, and that their side effects, such as nausea, can gradually disappear and constipation can be corrected by dietary modification and medication use. When using opioids in the elderly, attention should be paid to starting with the smallest dose, using immediate release formulations, titrating the drug dose to control pain, and then changing to controlled release or extended release formulations to maintain a stable blood concentration and reduce tolerance. For neuropathic pain in the elderly, antidepressants, anticonvulsants and antiarrhythmics can also be used. Amitriptyline, a tricyclic antidepressant, is more effective than other classes of antidepressants in the treatment of neuropathic pain. The traditional anticonvulsants carbamazepine and phenytoin are less used in pain treatment because of their side effects, but carbamazepine is still the first-line drug for trigeminal neuralgia. The new anticonvulsant gabapentin has recently been used in the treatment of neuropathic pain in China. Some data show that gabapentin is effective in diabetic neuropathy and postherpetic neuralgia, and the adverse effects are significantly less than those of traditional anticonvulsants. The antiarrhythmic drugs mexiletine, flecainide, and lidocaine may be used to treat neuropathic pain where other treatments have failed. For pain caused by fracture laxity in the elderly, calcitonin and diphosphates may be considered. It is worth noting that these drugs have an effect on heart, liver and kidney function, and need to be chosen according to each individual’s specific situation when treating. 2. Non-pharmacological treatment Non-pharmacological treatment includes physical therapy, minimally invasive interventional therapy and psychotherapy, etc. 1. Physical therapy There are many types of pain physical therapy, including light therapy, electrical therapy, magnetic therapy, ultrasound therapy, hydrotherapy, massage, etc. Physiotherapy can be combined with drug therapy, which helps to increase local blood circulation, relieve pain, enhance muscle strength and improve the range of motion of the elderly. However, special attention should be paid to the massage must be operated by a specialist, do not blindly to the informal small clinics massage therapy. Because the massage does not play a direct therapeutic role, if improper treatment, but also aggravate the disease. The elderly often have osteoporosis, if the massage is too hard, often resulting in fractures, especially in the cervical and lumbar spine osteophytes of the elderly, more easily massage therapy, if the massage does not cause fractures, often nerve damage, and even paralysis, the consequences are unthinkable. 2, minimally invasive interventional treatment for drug therapy, physical therapy is not effective in chronic intractable pain, consider the use of minimally invasive interventional treatment. Minimally invasive interventional therapy is widely carried out in domestic pain departments because it causes less damage to the human body and avoids the side effects of long-term drug treatment. Minimally invasive interventions for pain management in the elderly mainly include nerve blocks, electrical stimulation, percutaneous vertebroplasty, epidural lumpectomy and programmable morphine pump implantation. A nerve block is an injection of a drug into or next to a nerve or a physical needle prick into a nerve to give stimulation and block the nerve conduction function. Nerve blocks performed with local anesthetics not only relieve pain, but also stop pain conduction, block the vicious cycle of pain, release muscle tension and spasm, release vasoconstriction, improve ischemia and hypoxia, improve metabolism, improve blood flow status, and have anti-inflammatory effects. Many physicians prefer to add cortisol-based drugs when performing nerve blocks, but in elderly people, especially those with cardiovascular disease and diabetes, special attention should be paid to the side effects of cortisol and use it according to individual conditions. Nerve disruption is a long-term or permanent nerve block, divided into physical and chemical disruption, and radiofrequency disruption is recommended. The temperature of pulsed radiofrequency is controlled at 38-42℃, which only affects the sensory nerves and does not damage the motor nerve function. Radiofrequency disruption can be used not only to disrupt peripheral nerves, but also to disrupt the conduction tracts in the spinal cord such as the spinal thalamus and some nuclei in the brain to treat certain intractable pain. Spinal cord electrical stimulation (SCS) is particularly effective for neuropathic and injury-sensitive pain that does not respond well to common pain treatments. It generally involves percutaneous implantation of electrodes in the epidural space, and in a few cases, incision of the vertebral plate is required to place the electrodes. The electrodes are tested for 7-10 days after implantation and a pulse generator can be implanted for continuous stimulation once the pain is effectively controlled. Approximately 80% of patients have good results during the testing phase, which allows for further permanent electrode implantation. Follow-up studies have shown that about 70% of patients with neuropathic pain achieve satisfactory results after permanent electrode implantation, and 50% of patients with injury-sensitive pain achieve long-term analgesia after 6 months of observation. In addition, deep brain stimulation (DBS) and motor cortex stimulation by implanting electrodes into the brain can be used to treat patients with painful disabilities or those for whom various other means of treatment have failed. Many older adults have osteoporosis, and severe fracture laxity can cause compression fractures that lead to intractable pain. Percutaneous vertebroplasty is performed by percutaneously injecting a filler such as bone cement into the vertebral body of a compression fracture to enhance stabilization of the fractured vertebral body and reduce pain. It is mainly used when the pain is significant and medication alone is not effective, when the pain is not due to other causes by imaging, and when the compression of the vertebral body should be at least 1/3 of the original height of the vertebral body, but not when the height of the vertebral body is more than 75% compressed, when the fracture involves the posterior wall of the vertebral body, and when the fracture fragment compresses the structures in the spinal canal. The main complications are cement leakage, arch fracture, fat embolism and pulmonary embolism. In recent years, the development of fiberoptic guidance technology and endoscopy has enabled the use of epidural laparoscopy in clinical practice. With this technique, the doctor can place a needle into the sacral epidural cavity under X-ray fluoroscopic guidance, look directly at the epidural cavity contents, and perform image diagnosis or treatment. It can be used to treat epidural fibrosis in the elderly, long-term postoperative pain in the low back, foraminal or lateral saphenous fossa stenosis and nerve root injury. Programmable morphine pump implantation involves placing a special catheter in the subarachnoid space and then implanting a programmable morphine pump under the patient’s skin, connecting the catheter to the pump using a subcutaneous tunnel. The pump contains a reservoir to store the morphine solution, and the pump’s infusion system provides a continuous slow and uniform infusion of the drug into the cerebrospinal fluid in the subarachnoid space through the catheter to achieve pain control. Since morphine acts directly on the endorphin receptors in the spinal cord and brain, a small amount of morphine can achieve satisfactory analgesic effects and reduce the side effects caused by systemic administration of morphine. The drug reservoir can be injected repeatedly and the concentration of the drug can be changed. It is also possible to remotely adjust the infusion rate of morphine pump without surgery according to the condition. At present, it is mostly used in China for the treatment of cancer pain. In foreign countries, local anesthetics, ketamine and colistin are also put into the infusion pump to treat neuropathic pain. Psychological treatment Depression and tension are more common in the elderly, and pain can increase the chance of occurrence. There is a clear correlation between chronic pain and depression in the elderly, and the number of elderly people complaining of depressive symptoms in chronic pain is significantly higher than in other age groups. For example, elderly people who live in a normal environment and are responsible for many household activities can become pessimistic and even doubt the value of their existence once their chronic pain increases, limiting their household chores and their ability to perform daily activities, which can eventually lead to depression. In other words, chronic pain → activity dysfunction → restriction of daily activities → depression. Therefore, patients with chronic pain and depression should be treated not only with pain treatment but also with psychotherapy. Psychological treatment methods include cognitive behavioral therapy, relaxation therapy, operant behavior therapy, and biofeedback therapy. The central goal of cognitive-behavioral therapy is to reduce or eliminate the influences that cause undesirable behavioral tendencies, thoughts and beliefs related to the patient’s pain. Relaxation therapy involves relaxation training to reduce the patient’s anxiety and depression. Operant behavior therapy is the treatment of pain with reward-reinforcement and punishment-elimination based on the principle of conditioned reflexes. If the patient learns and emerges a new, good behavior, we immediately reward it so that the new behavior is reinforced and the bad behavior is weakened. In addition to this, records or charts are used to show the progress of the patient’s physical exercise and the improvement of his or her abilities, so that the patient feels the ability to gradually control and eventually overcome the disease. And biofeedback therapy is based on the fact that patients with chronic pain will have a series of emotional changes, resulting in changes in heart rate, ECG, pulse, blood pressure, electromyography and other biophysiological information. If these information that they are not aware of is amplified by detection and displayed by light, meters, numbers or graphs, and fed back to them through eyes and ears, through specific training, patients can learn to control themselves in order to achieve their own control of emotions and Promote the recovery of function and achieve the purpose of rehabilitation. Through these treatments, the elderly are helped to cope with pain problems, self-control their emotions and improve their quality of life. In conclusion, with the arrival of the aging society, paying attention to the elderly and their pain problems has become an important aspect of pain treatment in China.